Medical Attendant Rules - Central Government Health Scheme

Central Government Health Scheme

(CGHS)

The medical facilities under the Central Government Health Scheme are available to all the employees paid from the civil estimates and their family members residing in the area covered by the scheme.
An employee can opt out of the scheme and avail of the medical facilities provided by the employer of his spouse. If an employee or a member of his family covered under the Scheme falls ill at a place not covered under CGHS, the treatment shall be admissible under CS(MA) Rules.

The medical facilities to the Central Government employees and their dependent family members are provided under the Central Government Health Scheme in the following cities:

• Shillong
• Ahmedabad
• Ghaziabad
• Meerut
• Allahabad
• Gurgaon
• Mumbai
• Bangalore
• Guwahati
• Nagpur
• Bhubaneshwar
• Hyderabad
• Noida
• Kolkata
• Jaipur
• Patna
• Chennai
• Jabalpur
• Pune
• Kanpur
• Ranchi
• Delhi/New Delhi
• Faridabad
• Lucknow
• Thiruvananthapuram

Definition of Family :-
‘ Family’ means employee’s

(i) Husband/Wife including more than one wife and also judicially separated wife.

(ii) Parents and Stepmother. In the case of adoption, only the adoptive and not the real parents. If the adoptive father has more than one wife, the first wife only. A female employee has a choice to include either her parents or her parents-in-law; option exercised can be changed only once during service.

(iii) Children including legally adopted children, stepchildren and children taken as wards subject to the following conditions : Son -Till he starts earning, irrespective of age limit.
Daughter -Till she starts earning or gets married, whichever is earlier, irrespective of age-limit. Son suffering from Permanent disability of any kind (physical or mental) -No age -limit.

(iv) Widowed daughters and dependent divorced/separated daughters. (v) Sisters including widowed sisters.

(vi) Minor borthers and dependent brothers. But the above persons should reside with the government servants and their income from all sources should not be more than Rs.1500/- per month.

Contribution:-
A compulsory monthly contribution is charged from all the entitled classes of government servants on the basis of rates fixed by the government from time to time. The present rates of contribution are as under:

Pay.......................Rate of monthly contribution (Rs.)
Up to Rs.3000/- ....................15/-

Rs.3001 to 6000/- ................40/-

Rs.6001 to 10000/-...............70/-

Rs.10001 to 15000/-...........100/-

Rs.15001/- and above-.......150/-

Grant of medical advances:-
Delegation of power for settlement medical reimbursement / grant of medical advances.
Up to Rs.2 Lakhs (Serving Employees) - Head of Department

Up to Rs.2 Lakhs (Pensioners) - Head of Concerned CGHS covered city

Claim exceeding Rs.2 Lakhs - Ministry / Department in consultation with internal

Financial Division

Husband and wife are Central Government servants:-

When both husband and wife are Central Government servants covered by the scheme, the contribution will be recovered from only one of them whose pay is higher.

Procedure for reference to Referral/Recognised Hospitals under CGHS
The beneficiaries will have the option to avail specialised treatment at CGHS recognised hospitals of his/her choice if the specialist of the CGHS dispensary or government hospital recommends the patient for such specialised treatment. After the specialist advises a procedure in writing, the permission letter for taking such treatment in a CGHS recognised private/referral hospital of the choice of the employee in the same city, would be given by the parent department/office. In case the beneficiary, inspite of the facility being available in the city still chooses to get treatment in another city, permission of the CGHS authorities of the city would have to be obtained. In such cases, no TA/DA will be paid by the government. The government servant is allowed to take treatment from referral/recognised hospitals under CGHS in emergency. However, the term 'emergency' will be decided by the Additional Director, CGHS concerned whether the case is/was of real 'Emergency' before reimbursement is made by the parent department on the basis of rates fixed by the CGHS from time to time. Ex post facto permission for treatment in government referral hospitals like PGI Chandigarh etc. can be given by the parent department.
Medical Advance - The medical advance to the serving government servant for self treatment or treatment of the dependents on receipt of estimate from the treating doctor of a government/recognised hospital is available subject to the following conditions:

i) Rs.10,000/- or the amount recommended by the doctor, whichever is less for indoor treatment in hospital and for OPD treatment in case of TB/Cancer.

ii) In case of major illness like by-pass urgery, kidney transplant etc., the advance may be limited to 90% of the package deal wherever it exists or the amount demanded by the hospital concerned.

iii) The advance is paid directly to the hospital concerned on receipt of an estimate.

iv) For settlement of advance, the employee concerned may be required to submit the adjustment bills within a period of one month from the date of his discharge from the hospital. In case the entire advance has not been utilised for the treatment of the patient, the head of office concerned will correspond with the hospital for refund of the unutilised balance of medical advance.

Settlement of Claim -

The government servant is required to prefer claim/bill within 3 months, from the date of discharge from the hospital. If the claim gets time barred, relaxation of delay is allowed by the department depending on the circumstances of delay. The claim should have the following documents completed:

a) Claim Form Med. '97' and Essentiality Certificate ‘A’ for Outdoor treatment and 'B' for Indoor treatment.
b) All original bills verified by the treating doctor with his stamp.
c) Photocopy of CGHS Token Card.
d) Discharge Summary of the Hospital in case of Indoor Treatment.
e) A detailed list of all medicines, laboratory tests, investigations, number of doctors visits etc.
f) Self explanatory letter from the beneficiary and referrel letter fromAMA doctor should be submitted in case of emergency.
g) Legal heir certificate in case of death of the card holder.
Based on the rates fixed by the CGHS, the admissible amount is worked out by the department. If the rates claimed by the concerned are less than the rates fixed by the government, the actual amount is reimbursed. In case CGHS rates are not available for a particular item, the reimbursement is allowed on the basis of rate list of AIIMS. Incidentally, where AIIMS rates are also not available, the actual amount paid by the patient is reimbursed. Items mentioned in the list of inadmissible items under CS(MA) Rules are not reimbursable. Special Nursing Charges are to be reimbursed as fixed by the Ministry of Health from time to time.